Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420190008&lang= vol. 109 num. 8 lang. <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Caster Semenya - the questionable practice of gender verification</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800001&lng=&nrm=iso&tlng= <![CDATA[<b>New recurring <i>BRCA1 </i>variant: An additional South African founder mutation?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800002&lng=&nrm=iso&tlng= <![CDATA[<b>The case for stool banks in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800003&lng=&nrm=iso&tlng= <![CDATA[<b>The case for stool banks in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800004&lng=&nrm=iso&tlng= <![CDATA[<b>Global injustice in sport: The Caster Semenya ordeal -prejudice, discrimination and racial bias</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800005&lng=&nrm=iso&tlng= The International Association of Athletics Federations (IAAF) requires the blood testosterone level of female athletes with differences of sex development to be reduced to below 5 nmol/L for a continuous period of at least 6 months, and thereafter to be maintained to below 5 nmol/L continuously for as long as the athlete wishes to remain eligible. Its ruling is based on questionable research findings. Medical decisions and interventions should be based on evidence from well-designed and well-conducted research and confirmatory studies. Caster Semenya, the reigning 800-meter Olympic champion since 2015, has challenged this ruling. Gender verification was instituted with women's participation in the Olympics in 1900, and female athletes were subjected to invasive, embarrassing and humiliating procedures. In its many decades of harsh scrutiny of successful female athletes, especially those from backgrounds similar to Semenya's, the IAAF has disrespected human rights and medical ethics and allowed prejudice, discrimination and injustice to infringe on their dignity and relentlessly obstruct their international sporting careers. <![CDATA[<b>Would it be ethical or legal for doctors in South Africa to administer testosterone-reducing drugs to Caster Semenya?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800006&lng=&nrm=iso&tlng= The Court of Arbitration for Sport recently confirmed that the decision by the International Association of Athletics Federations to require hyperandrogenic female athletes such as Caster Semenya to reduce their testosterone levels to compete in certain races has been widely condemned. The World Medical Association has warned doctors not to assist in implementing the decision, as it would be unethical. The same would apply in terms of the Health Professions Council of South Africa's rules of professional conduct. Such treatment is 'futile' in medical terms, and does not serve the purpose of providing healthcare. Therefore, doctors may lawfully refuse to prescribe it. The decision is a violation of Semenya's constitutional rights and would be regarded as unethical should doctors comply with it. However, the prescription of such drugs would not be unlawful if Semenya gave informed consent to taking them. Such consent would not be a defence to a disciplinary hearing on unprofessional conduct, but would be a good defence to any legal action arising from unpleasant side-effects - provided they were explained to her. <![CDATA[<b>Tuberculosis infection control in a South African rural regional hospital emergency centre: Prioritisation for patients and healthcare workers</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800007&lng=&nrm=iso&tlng= South Africa (SA) is in the midst of a tuberculosis (TB) epidemic and has one of the highest TB incidence rates globally. Despite increasing global commitment to eliminate TB, SA appears to be falling behind in this regard. This article examines key challenges to effective TB infection control from a rural regional hospital perspective. It uses the Eden District in Western Cape Province as an example to share lessons learnt. This quality-improvement project identifies four priorities for improving TB infection control in George Hospital and the Eden District: (i) prioritising TB infection control in local policy; (ii) improving the quality of TB screening in the emergency centre; (iii) increasing the number of TB patients followed up; and (iv) implementing TB infection control training for all staff. This project demonstrates the role of an emergency centre in TB screening, highlighting that this should not only be a priority for primary care, but also for secondary and tertiary care. Simple interventions, such as training of local healthcare workers in TB infection control and good-quality TB screening, can initiate a behavioural change. It also stresses the importance of good communication and co-ordination of care across primary and secondary care, ensuring that patients are not lost to follow-up. Local policy needs to reflect these straightforward interventions, empowering local healthcare workers and managers to increase responsibility and accountability for TB infection control.TB is preventable, and infection control needs to become a priority throughout SA primary, secondary and tertiary care. This project highlights that simple interventions, such as engaging local healthcare workers in a co-ordinated multisystem and multidisciplinary approach, could help to reduce the number of missing TB cases and bring SAs TB epidemic under control. <![CDATA[<b>Migration of etonogestrel contraceptive implants: Implications for difficult removals services need in southern Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800008&lng=&nrm=iso&tlng= The first difficult contraceptive implant removals clinic in sub-Saharan Africa was started 2 years ago at New Somerset Hospital in Cape Town, South Africa, and has seen two cases of implant migration. We report these cases here. The first was a case of fascial migration and the second one of migration via the cephalic vein, both to a site just anterior to the glenohumeral joint. Both implants were removed without complications. Even with correct insertion technique, migrations can occur. Healthcare providers need to know how to manage difficult removals, and how to access and refer to difficult removals services when necessary. These services must therefore be available in all settings where implants are offered, to ensure access to rights-based family planning services for all women in southern Africa. <![CDATA[<b>Factors associated with missed and delayed DTP3 vaccination in children aged 12 - 59 months in two communities in South Africa, 2012 - 2013</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800009&lng=&nrm=iso&tlng= BACKGROUND: Although immunisation services are available to all children in South Africa (SA), many children miss or have delays in receiving vaccines. There are limited data on factors associated with missed or delayed vaccination in children in this setting.OBJECTIVES: To assess vaccination coverage and factors associated with missed and delayed diphtheria-tetanus-pertussis vaccine third dose (DTP3) vaccination in children aged 12 - 59 months in two SA communities.METHODS: We used data from household-level healthcare utilisation surveys conducted in Soweto in 2012 and in Pietermaritzburg in 2013. Information on vaccination status was recorded from the Road to Health cards or vaccination history from clinics for children aged <5 years. Factors associated with missed or delayed DTP3 vaccination were assessed using unconditional logistic regression.RESULTS: Of a total of 847 eligible children aged 12 - 59 months, 716 had available vaccination information. Overall DTP3 vaccination coverage was high for both sites: 90.6% in Pietermaritzburg and 93.9% in Soweto. However, 32.6% and 25.2% of DTP3 vaccinations were delayed (received after 18 weeks of age) in Pietermaritzburg and Soweto, respectively. The median delay for DTP3 vaccinations was 4.7 weeks (interquartile range 1.7 - 23.0). Factors associated with delayed DTP3 vaccination included being born in 2010 (adjusted odds ratio (aOR) 3.0, 95% confidence interval (CI) 1.4 - 6.3) or 2011 (aOR 2.7, 95% CI 1.3 - 5.7) compared with being born in 2008, probably due to vaccine shortages; a low level of education of the primary caregiver, with children whose caregivers had completed secondary education having lower odds of delayed vaccination (aOR 0.5, 95% CI 0.3 - 0.9) than children whose caregivers only had primary education; and maternal HIV status, with unknown status (aOR 3.5, 95% CI 1.6 - 7.6) associated with higher odds of delay than positive status. Factors associated with missed DTP3 vaccination (not vaccinated by 12 months of age) included two or more children aged <5 years in a household (aOR 2.4, 95% CI 1.2 - 4.9) compared with one child, and household monthly income <ZAR500 (aOR 3.4, 95% CI 1.1 - 11.4) compared with &gt;ZAR2 000.CONCLUSIONS: Despite high overall DTP3 coverage observed in two communities, many vaccinations were delayed. Vulnerable groups identified in this study should be targeted with improved vaccination services to enhance uptake and timeliness of vaccination. <![CDATA[<b>Detection of splenic microabscesses with ultrasound as a marker for extrapulmonary tuberculosis in patients with HIV: A systematic review</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800010&lng=&nrm=iso&tlng= BACKGROUND: In 2015, 1.2 million new cases of tuberculosis (TB) were diagnosed in patients with HIV. Diagnostic limitations and resource shortages in endemic areas can delay diagnosis and treatment, particularly with extrapulmonary TB (EPTB). Research suggests that ultrasound can identify splenic microabscesses caused by EPTB, but data are limited on the frequency of this finding in patients with culture-proven EPTBOBJECTIVES: To estimate the frequency of splenic EPTB microabscesses detected with ultrasound in patients with HIV and TB co-infectionMETHODS: Studies published in six major databases as of November 2017 were systematically reviewed based on the PRISMA guidelines. Cohens kappa test was used to determine inter-rater agreement. Articles included for data abstraction passed the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) evaluation. Freeman-Tukey transformation was used to calculate weighted proportions. Heterogeneity was evaluated by Forest plot and Ρ calculationRESULTS: After abstract screening, article review and QUADAS-2 evaluation, five studies were selected for data extraction. A total of 774 patients in these studies were infected with HIV. Splenic lesions were seen with ultrasound in 21.0% of patients with HIV (95% confidence interval (CI) 10.6 - 33.8). TB diagnosed by culture, biopsy, smear, or molecular methods was found to be the cause of 88.3% (95% CI 72.3 - 97.9) of splenic microabscesses seen on ultrasound in patients with HIVCONCLUSIONS: Ultrasound evaluation of the spleen in patients with HIV and symptoms suggestive of TB in endemic regions is a viable diagnostic adjunct. Ultrasound detection of splenic microabscesses in HIV patients is probably sufficient indication to initiate TB treatment prior to obtaining culture data. Strong conclusions cannot be drawn owing to the high heterogeneity of this small number of studies <![CDATA[<b>An analysis of the direct cost of renal dialysis provided through a public-private partnership at a tertiary hospital in Limpopo Province, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800011&lng=&nrm=iso&tlng= BACKGROUND: Chronic kidney disease (CKD) is increasingly recognised as an important cause of morbidity and mortality in South Africa (SA). Although the cost of dialysis is well documented in developed countries, little is known about this cost in sub-Saharan Africa.OBJECTIVES: To review the costs of providing peritoneal dialysis (PD) and haemodialysis (HD) at the Pietersburg renal dialysis public-private partnership (PPP) unit in Limpopo Province, SA.METHODS: A retrospective review of the cost of inputs required for HD and PD was conducted from a provider's perspective, covering the period 2007 - 2012. A top-down approach was used to estimate the average annual cost per patient on HD and PD.RESULTS: During the 6-year period under review, the number of patients on dialysis increased from 77 in 2007 to 182 in 2012. More than 60% of the patients were on HD. The average annual cost per patient was estimated to be ZAR212 286 (USD25 888) and ZAR255 076 (USD31 106) for HD and PD, respectively, in 2012. Personnel cost, PD supplies, HD supplies, the outsourcing fee and pharmaceutical supplies were the main cost drivers. PD proved to be more expensive than HD, despite the use of locally manufactured fluids.CONCLUSIONS: The study highlights the exceptionally high cost of dialysis treatment. Dialysis should be made more accessible by implementing measures to address the main cost drivers. Moreover, a comprehensive approach that includes prevention of CKD at primary healthcare level, an organ donation programme and an effective kidney transplant programme is urgently required in Limpopo. Further research is required to evaluate the cost-effectiveness of the PPP approach. <![CDATA[<b>Hepatitis E virus in patients with acute hepatitis in Cape Town, South Africa, 2011</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800012&lng=&nrm=iso&tlng= BACKGROUND: Early hepatitis E virus (HEV) seroprevalence studies in South Africa (SA) showed seroprevalence rates of 2 - 10%, and suggested waterborne transmission. More recent studies in Cape Town, SA, reported HEV seroprevalence rates of 28% and 26% in outpatients without liver disease and blood donors, respectively. An association was found with eating pork or bacon/ham. Only 3 human cases of hepatitis E in SA have been reported in the literatureOBJECTIVES: To find evidence of HEV infection in hospitalised patients with acute hepatitis and no other identified causeMETHODS: Leftover serum samples were retrieved for patients negative for hepatitis viruses A, B and C, where no other cause of hepatitis was identified. Samples were tested for HEV by polymerase chain reaction (PCR) and IgM and IgG enzyme-linked immunosorbent assay (ELISARESULTS: Anti-HEV IgG was detected in 39/132 specimens (29.5%; 95% confidence interval (CI) 22.4 - 37.8), and anti-HEV IgM in 2/125 specimens (1.6%; 95% CI 0.4 - 5.7). No specimen tested positive by PCRCONCLUSIONS: IgG seroprevalence found in this study was similar to that previously reported in Cape Town. IgM positivity in 2 patients was not confirmed by PCR. Locally, hepatitis E may not be a common cause of clinically apparent hepatitis that requires hospitalisation <![CDATA[<b>Hepatitis E in pig-derived food products in Cape Town, South Africa, 2014</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800013&lng=&nrm=iso&tlng= BACKGROUND: Hepatitis E virus (HEV) genotypes 3 and 4 are zoonoses, with domestic pigs being the most important reservoir. A high anti-HEV IgG seroprevalence of 26 - 28% has been found in humans in Cape Town, South Africa (SA). Studies in industrialised countries have indicated a high prevalence of HEV in pigs and their associated food productsOBJECTIVES: To determine whether HEV could be found in pig-derived food products in Cape TownMETHODS: Pork-containing food products were purchased from supermarkets and butcheries around the Cape Town metropolitan area. HEV detection by polymerase chain reaction (PCR) was performed, and an amplified viral genome fragment was sequenced from positive samples. Phylogenetic analysis was done on the sequenced fragmentRESULTS: HEV was detected by PCR in 2/144 food samples - both were liver spread samples. One genome fragment sequence was obtained, which was closely related to HEV sequences obtained from humans in Cape TownCONCLUSIONS: HEV can be found in pork-containing meat products available for sale in Cape Town, suggesting that these products could be a potential source of HEV transmission in our geographical area. Meat of pig origin should be thoroughly cooked before being consumed <![CDATA[<b>An observational study of safe and risky practices in funeral homes in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800014&lng=&nrm=iso&tlng= BACKGROUND: Funeral home personnel are at risk of exposure to infectious hazards. The high prevalence of infectious diseases in South Africa means that these workers and family members of deceased individuals are vulnerable to infection if proper safety measures and equipment are not usedOBJECTIVES: To collect observational information on funeral industry practices in order to assess the safety of handling corpses and exposure to risk that could result in disease transmissionMETHODS: A cross-sectional study was conducted across two locations from August to October 2015. Funeral homes in Klerksdorp and Soweto were approached. The study team did facility assessments and observed preparation practices, focusing on safety equipment, personal protective equipment (PPE) and contact with hazardous materials. Interviews with funeral home personnel and relatives of the deceased were also conductedRESULTS: Of the funeral homes, 23.0% (20/87) agreed to participate. A median of 5 personnel (interquartile range 4-8) were employed per facility. It was observed that not all PPE was used despite availability. Gloves, aprons and face masks were most commonly worn, and no personnel were observed wearing boots, gowns or plastic sleeves. Funeral homes were located near food outlets, schools and open public spaces, and not all had access to proper biohazardous waste disposal services. Of 5 family members who were interviewed for the study, none reported being willing to partake in the funeral preparation procedureCONCLUSIONS: There is a need to standardise the use of safety equipment, waste disposal methods and location designation in the funeral industry <![CDATA[<b>The changing landscape of infective endocarditis in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800015&lng=&nrm=iso&tlng= BACKGROUND: Little is known about the current clinical profile and outcomes of patients with infective endocarditis (IE) in South Africa (SAOBJECTIVES: To provide a contemporary and descriptive overview of IE in a representative SA tertiary centreMETHODS: We conducted a retrospective review of the records of patients admitted to Groote Schuur Hospital, Cape Town, between 2009 and 2016 fulfilling universal criteria for definite or possible IE, in search of demographic, clinical, microbiological, echocardiographic, treatment and outcome informationRESULTS: A total of 105 patients fulfilled the modified Duke criteria for IE. The median age of the cohort was 39 years (interquartile range (IQR) 29 - 51), with a male preponderance (61.9%). The majority of the patients (72.4%) had left-sided native valve endocarditis, 14.3% had right-sided disease, and 13.3% had prosthetic valve endocarditis. A third of the cohort had rheumatic heart disease. Although 41.1% of patients with left-sided disease had negative blood cultures, the three most common organisms cultured in this subgroup were Staphylococcus aureus (18.9%), Streptococcus spp. (16.7%) and Enterococcus spp. (6.7%). Participants with right-sided endocarditis were younger (29 years, IQR 27 - 37) and were mainly intravenous drug users (73.3%), and the majority cultured positive for S. aureus (73.3%) with frequent septic pulmonary complications (40.0%). The overall in-hospital mortality was 16.2%, with no deaths in the group with right-sided endocarditis. Predictors of death in our patients were heart failure (odds ratio (OR) 8.16, 95% confidence interval (CI) 1.77 - 37.70; p=0.007) and age >45 years (OR 4.73, 95% CI 1.11 - 20.14; p=0.036). Valve surgery was associated with a reduction in mortality (OR 0.09, 95% CI 0.02 - 0.43; p=0.001CONCLUSIONS: IE remains an important clinical problem in a typical teaching tertiary care centre in SA. In this setting, it continues to affect mainly young people with post-inflammatory valve disease and congenital heart disease. The in-hospital mortality associated with IE remains high. Intravenous drug-associated endocarditis caused by S. aureus is an important IE subset, comprising -10% of all cases, which was not reported 15 years ago, and culture-negative endocarditis remains highly prevalent. Heart failure in IE carries a significant risk of death and needs a more intensive level of care in hospital. Finally, cardiac surgery was associated with reduced mortality, with the largest impact in patients with heart failure <![CDATA[<b>Trends and inequities in amenable mortality between 1997 and 2012 in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800016&lng=&nrm=iso&tlng= BACKGROUND: Amenable mortality comprises causes of death that should not occur with timely and effective healthcare. It is commonly used to assess healthcare performance. It could also be used to assess the effectiveness of the pending National Health Insurance (NHI) in South Africa (SA), but to do this, the level and distribution of amenable mortality are required using a local list of amenable causesOBJECTIVES: To establish an amenable cause-of-death list appropriate for SA and to determine the levels, trends, geographical distribution, population group differences and international comparisons of mortality amenable to healthcareMETHODS: A local list of amenable causes of death was developed with input from public health and disease-specific medical experts. The Second SA National Burden of Disease estimates were reclassified into amenable mortality. Analyses of age-standardised death rates (ASDRs) and amenable mortality proportions were conducted by province and population group between 1997 and 2012. Excess mortality in relation to the best-performing province and population group was also analysed. ASDRs for SA were compared with those of European Union (EU) and Organisation for Economic Co-operation and Development (OECD) countriesRESULTS: The local list of amenable conditions contained 45 causes of death. There were large disparities in amenable mortality between provinces and population groups, which did not attenuate over time. There was an average annual percentage increase in amenable ASDRs, but when HIV/AIDS was excluded from the analysis there was an average annual decrease of 1.12%. In the post-peak HIV/AIDS period between 2008 and 2012, an annual average of 207 810 amenable deaths could have been saved if all provinces had the same ASDR as the Western Cape. SAs ASDR was 2.6 and 2.2 times higher than that of the worst-performing EU and OECD country, respectivelyCONCLUSIONS: This is the first study known to the authors that has established a local amenable mortality list and described the epidemiology of amenable mortality in SA. Amenable mortality could be used as an indicator of the performance of the pending NHI over time and, in combination with other indicators, could identify areas of the health system that require improvement. Benchmarking could also quantify gaps in health system performance between geographical regions and indicate whether these are reduced with time <![CDATA[<b>IAP ASSA SAGES Congress 2019. 16 - 20 August 2019, Cape Town International Convention Centre </b><b><a href="http://www.assasages.co.za" target="_blank">www.assasages.co.za</a></b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742019000800017&lng=&nrm=iso&tlng= BACKGROUND: Amenable mortality comprises causes of death that should not occur with timely and effective healthcare. It is commonly used to assess healthcare performance. It could also be used to assess the effectiveness of the pending National Health Insurance (NHI) in South Africa (SA), but to do this, the level and distribution of amenable mortality are required using a local list of amenable causesOBJECTIVES: To establish an amenable cause-of-death list appropriate for SA and to determine the levels, trends, geographical distribution, population group differences and international comparisons of mortality amenable to healthcareMETHODS: A local list of amenable causes of death was developed with input from public health and disease-specific medical experts. The Second SA National Burden of Disease estimates were reclassified into amenable mortality. Analyses of age-standardised death rates (ASDRs) and amenable mortality proportions were conducted by province and population group between 1997 and 2012. Excess mortality in relation to the best-performing province and population group was also analysed. ASDRs for SA were compared with those of European Union (EU) and Organisation for Economic Co-operation and Development (OECD) countriesRESULTS: The local list of amenable conditions contained 45 causes of death. There were large disparities in amenable mortality between provinces and population groups, which did not attenuate over time. There was an average annual percentage increase in amenable ASDRs, but when HIV/AIDS was excluded from the analysis there was an average annual decrease of 1.12%. In the post-peak HIV/AIDS period between 2008 and 2012, an annual average of 207 810 amenable deaths could have been saved if all provinces had the same ASDR as the Western Cape. SAs ASDR was 2.6 and 2.2 times higher than that of the worst-performing EU and OECD country, respectivelyCONCLUSIONS: This is the first study known to the authors that has established a local amenable mortality list and described the epidemiology of amenable mortality in SA. Amenable mortality could be used as an indicator of the performance of the pending NHI over time and, in combination with other indicators, could identify areas of the health system that require improvement. Benchmarking could also quantify gaps in health system performance between geographical regions and indicate whether these are reduced with time